Neehr Perfect Activity: Retrieval of Data Using your knowledge of the Neehr Perf
ID: 127789 • Letter: N
Question
Neehr Perfect Activity: Retrieval of Data
Using your knowledge of the Neehr Perfect EHR, locate the following data from Ms. Bowers’ chart.
1, Ms. Bowers was diagnosed with Angina, Unstable. Click on this problem in her chart.
a, What is the ICD-9 code for this diagnosis?
b, What is the ICD-10 code for this diagnosis?
To find the ICD-10 code, click on the Problems tab. Then click on New Problem on the left side of the screen.
(You may be prompted to choose an Encounter Provider. Choose your instructor and click OK).
Type Angina in the Search box that pops up and click Search. Search for the ICD-10 code for Unstable Angina. The ICD-9 codes are at the top of the list; you will need to scroll down to find the ICD-10 code.
Once you have located the ICD-10 code click Cancel to close the search box.
2, Was Ms. Bowers admitted to the hospital? How do you know?
3, Did Ms. Bowers receive oxygen while at the hospital? Where did you find this information?
4, What was Ms. Bowers’ initial blood pressure? Where did you find this information?
5, Was Ms. Bowers given any medication while in the ER?
a, If so, what medication was given?
b, Where did you find this information?
6, Which of the following protocols was followed by the emergency department staff? Hint: Read the notes in the Notes tab of Ms. Bowers’ chart.
a, Acute Coronary Syndrome Protocol
b, Standard Precautions Protocol
c, Heparin Administration Protocol
Critical thinking questions
According to the chart documentation, many tests and assessments were completed on Ms. Bowers immediately after she arrived to the ER. Below is a link to the nationally recognized protocol for Acute Coronary Syndromes, as well as a screenshot of an excerpt from an ACS protocol flowchart for the care of each patient that is suspected of having an acute coronary “event.”
Using Step #3 from the screenshot and the identified sections from the Acute Coronary Syndrome webpage, answer the following questions. (See “additional resources” for additional documents to review.)
Go to the Internet and copy and paste this link into the search window:
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-9-acute-coronary-syndromes/
Read the following sections of the webpage in order to answer these questions: Sections 4, 6.2.1, and all of section 7.
Briefly list the guidelines, or protocol, of ACS once a patient has arrived at the hospital. According to the documentation in the chart, was Ms. Bowers treated per the protocol? Why or why not?
Explanation / Answer
1. Ms. Bower was diagnosed with angina, Unstable:
a. ICD-9 code for the diagnosis 411.1
b. ICD-10 code for the diagnosis 120.0
2. Yes. Mr. Bower was admitted to the Hospital. There are orders in the chart for admitting Ms.Bower under medical observation.
3. Yes. MS. Bower receives oxygen while she is in the hospital via per Nasal cannula at oxygen stats of greater than 92%. The Order for oxygen presents in the order's tab.
4. MS. Bower's initial Blood pressure is 150/90 mmHg. This information present in Notes tab April 2016, under Medic: Urgent care, Cardiac.
5. Yes. Ms. Bower's was treated with the following medication in the ER:
a. IV fluid 9% NS 1L to flow over 4hrs at a rate of 250mL/hr, ASA 325 to chew.
b. This information is found in Notes tab, Nurse: ER Note, Emergency.
6. The protocol followed by the Emergency staff is
a. Acute Coronary syndrome protocol.
The guidelines / Protocols of ACS:
Yes. Ms. Bower was treated as per the protocol. They not yet ruled out ACS.
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